David K. Pegram Manager - US DOE Accident Prevention and Investigation Program

1. DOE Accident Prevention andInvestigation Program UpdateMay 2012 - DOE Facility Representative and Fire Safety Workshop – Las Vegas NV. David K. Pegram Manager - US DOE Accident Prevention and Investigation Program Office of Health Safety and Security

2. A New Order for Accident Investigations DOE Order 225.1B states the requirements for accident investigation has been approved as revised March 4, 2011. Appointment of AI Boards now the responsibility of the heads of program elements (NA-1, EM-1, SC-1, etc.) Only one set of criteria for triggering AI’s (Type A and B merged into one – Federally Led Investigation).

3. New Handbook approach incorporates HPI/ISM into the Accident Investigation and Operational Safety Analysis methods.

4. Volume I: (Federal Led) Accident Investigations Volume I, discusses fundamental concepts of accident dynamics, accident prevention, and accident analysis. The focus is on improvement not placing blame. An understanding of the theoretical bases of safety management and accident analysis, and the practical application of the DOE Integrated Safety Management (ISM) framework, is presented.

6. Accident Prevention – Concepts

7. Conditions and Decisions - Context of Human Performance, and Safety Management Systems Flowcharting

8. Barrier Analysis HN – Human Nature IC – Individual Capabilities GP – Guiding Principles of ISM CF - Core Functions of ISM

9. Change Analysis

10. Volume II: (Contractor Led) Operational Safety Review (OSR) Volume II of the Accident and Operational Safety Analysis Handbook builds upon the concepts, philosophy, processes, and techniques presented in Volume I. Volume II is not intended to be a standalone volume, but supplements Volume I, with the key differences in the EXPANED analysis techniques for a Contractor Led - Operational Safety Review (OSR) in order to prevent accidents. Volume II has been structured using the same logical sequence for organizing a (Contractor) OSR team as for a(DOE) Federal Accident Investigation presented in Volume I.

11. Volume II: Operational Safety Review (OSR) The Operational Safety Review (OSR) is based on the premise that major accidents or incidents are not caused by individual errors, but are set up by the organizational environment the employee works in. It is not necessary to wait until a catastrophic accident for Contractors to use the investigation and analysis process defined in this handbook because the underlying organizational issues are at work all the time and can be preemptively identified through review of precursor incidents. Lesser consequential or information-rich events or negative trend indicators investigated using the OSR process can identify key organizational factors that if not identified and corrected, could lead to a more catastrophic event.

12. The OSR Differs from the AI in the OSRs Expanded Analysis – Digging Deeper into Organization Weaknesses

16. We need more people to volunteer as AI Board Members and Subject Matter Experts! http://www.hss.doe.gov/sesa/corporatesafety/aip/docs/SAF-230_AI_Courses_Information_and_Schedule.pdf Please take the time to volunteer as a subject matter expert by filling out a form at this meeting session! Consider enrolling in an up-coming AI Course thru the NTC.

17. Links, Websites, Resources • For more information: • The new DOE Order 225.1B, Accident Investigations, is at https://www.directives.doe.gov/directives/current-directives/225.1-BOrder-b/view • Accident Prevention and Investigation Program: • Reports from 1995 to present are available on the HSS/Corporate Safety Programs Website and E-Reference Tools http://www.hss.doe.gov/CSA/CSP/AIP/index.html

18. Questions? Contact:dave.pegram@hq.doe.gov 301-903-9840